Palliative care dentistry is “the evaluation and management of patients with active, progressive, advanced disease in whom the oral cavity has been compromised either by the disease directly or by its treatment, with a focus on the quality of life.” It plays an important role in the care of terminally ill patients with their oral needs. Most physicians and nurses in palliative care units or hospices focus their attention on other parts of the body than the mouths of the dying patients.
Sadly, many patients in palliative care have numerous oral issues: The most common problem is xerostomia and mouth dryness in 98% of patients. The other common oral issues include oral soreness (mucositis), thrush (candidiasis), dysphagia, denture problems, poor oral hygiene and difficulty talking. Recommendations for the management of dry mouth are frequent sipping of cold water, sucking on ice chips, using mouth moisturizer, spraying water-mist using an old-fashioned atomizer, chewing sugarless gum or sucking sugarless candies, taking medications that stimulate salivary flow, rinsing with mucin-
containing saliva substitutes, and gargling with enzyme-containing gels or rinses. For the patients who are frail and within weeks of living, swapping the mouth with a regular soft sponge moistened with xylitol water should be done as often as possible.
Generalized Oral Soreness (Mucositis) often happened in the mobile parakeratinized mucosal tissues (buccal mucosa, labial mucosa, soft palate, lateral tongue, and floor of the mouth), which have a high cell turnover rate. Patients who have undergone radiation therapy in the head and neck region can get it most of the time. The pain and sensitivity derived from the ulcer may keep patients from fully opening their mouths, which is uncomfortable and can interfere with eating and mouth care. Treatment methods for mucositis aim primarily to relieve pain and reduce inflammation. Caregivers can apply a topical numbing gel or rinse with benzocaine and a miracle mouth rinse or swap (a cocktail of milk of magnesium, tetracycline, hydrocortisone, and diphenhydramine, xylitol, etc.) to lower the pain and subside the inflammation. Before initiating any of the therapeutic measures, however, it is essential to identify and modify local traumatic factors, such as broken restorations or teeth or an impinging removable denture. Patients should be advised to avoid eating spicy foods and using tobacco and alcohol.
Candidiasis is an infection with a fungus of the genus Candida that usually occurs in the mouth, respiratory tract, or vagina; it may invade the bloodstream, especially in sick and immunocompromised individuals. Candidiasis in palliative care patients has been estimated to be 34% to 70%. Good oral hygiene combined with systemic and topical antifungal medications like nystatin therapy can be the first treatment choice for that condition.
Dysphagia is defined as difficulty swallowing. It often happens in patients who are near the end of their lives. Many healthcare providers consider it relatively trivial, and it is therefore unreported or underestimated. Other routes of food administration (intravenous nutrition or gastrostomy feeding tubes) may be used in patients who are unable to eat. However, the feeding tubes themselves likely create more pain for the patient and do not improve their lives’ quality or prolong them. Instead, liquid nutritional drinks should be spoon-fed to the patients by family members until the patients cannot take the liquid anymore.
The common cause of difficulty talking in palliative patients appears to be the result of the general disease progression that would affect intellectual capacity, memory, mood, concentration, and state of alertness. An evaluation by a dentist may help assess the presence of low saliva flow or a defective dental prosthesis, which could interfere with talking.
Sore mouth, candidiasis, dysphagia, and difficulty talking can all be attributed to ill-fitting dentures that dig into the oral tissues, create open wounds for infection and ulceration, or wobbling and flopping around during chewing and talking. When patients have poor oral hygiene and wear the dentures day and night without taking them out could also get candidiasis compounded with ulceration in the gum and palatal tissues. A simple adjustment or soft reline can help to alleviate the problems. Leaving the dentures, brushing and cleaning them with disinfectant or antifungal medications can improve oral candidiasis. Palliative care caregivers, who often have little or no training in oral healthcare, should be alerted to the presence of any dentures and should receive instructions for primary daily care. They can help to ensure that a denture brush, storage cup, and possibly effervescent cleaner are available. Denture problems that may frequently appear in palliative care patients include poor denture hygiene, loose dentures, nausea, and dentures with grossly poor fit. Denture adhesives should be used for dentures that are reasonably fit but loose.
Preventive Oral Care for Palliative Care Patients should include the following supplies/equipment:
- lip balm or petroleum jelly
- mouth sponge on a stick
- enzyme-containing gels or rinse
- ultrasoft toothbrushes and fluoride/xylitol-containing toothpaste
- floss or floss wands
- soft gauze
- denture brush, denture bowl, effervescent denture cleaning tablets and adhesive if the patient is wearing dentures
- kidney basin for spitting and thick towel as the bib when the patient is bed-ridden
Protocols should be established early and maintained throughout the palliative care process as integral components of the patient’s treatment plan. The palliative care that dentists provide can play an important role, along with that of other healthcare providers, in managing patients with advanced illnesses.
Being a general dentist in Burlington, I had first-hand experience with palliative dental care when my mom died a few years ago from cancer. I saw the rapid deterioration of her health and the incapability of maintaining oral health on her own during the last few weeks of her life. Any preventative oral care implemented before her incapacity and the palliative dental care provided during the final weeks of her life improved her quality of life to the last day.